I am Forbes' Opinion Editor. I am a Senior Fellow at the Manhattan Institute for Policy Research, and the author of How Medicaid Fails the Poor (Encounter, 2013). In 2012, I served as a health care policy advisor to Mitt Romney. To contact me, click here. To receive a weekly e-mail digest of articles from The Apothecary, sign up here, or you can subscribe to The Apothecary’s RSS feed or my Twitter feed. In addition to my Forbes blog, I write on health care, fiscal matters, finance, and other policy issues for National Review. My work has also appeared in National Affairs, USA Today, The Atlantic, and other publications. I've appeared on television, including on MSNBC, CNBC, HBO, Fox News, and Fox Business. For an archive of my writing prior to February 2011, please visit avikroy.org. Professionally, I'm the founder of Roy Healthcare Research, an investment and policy research firm. In this role, I serve as a paid advisor to health care investors and industry stakeholders. Previously, I worked as an analyst and portfolio manager at J.P. Morgan, Bain Capital, and other firms.

WEST PALM BEACH, FL - JULY 19: U.S. President Barack Obama delivers remarks to seniors at Century Village on July 19, 2012 in West Palm Beach, Florida. (Image credit: Getty Images via @daylife)

On the campaign trail, Mitt Romney has been criticizing President Obama for not proposing an agenda for his second term. “Although President Obama won’t lay out his plan for as second term,” said Romney in Florida last week, “we already know what it will be: a repeat of the last four years.” But in fact, Obama’s second term would look quite different from his first, because it’s in the next four years that Obamacare’s web of new taxes, spending increases, and regulatory mandates will be weaved. Here’s a timeline.

(DISCLOSURE: I am an outside adviser to the Romney campaign on health care issues. The opinions contained herein are mine alone, and do not necessarily correspond to those of the campaign.)

Obamacare was cleverly designed such that its most politically toxic provisions wouldn’t go into effect until after the election. In addition, the Obama administration spent billions of unauthorized taxpayer dollars this year and last so that the impact of its cuts wouldn’t be felt until after the election.

2013: Tax increases and Medicare cuts

Over the next ten years, Obamacare cuts $716 billion from the Medicare program in order to fund its $1.9 trillion in new health spending over the same period. $156 billion of those cuts come from the market-oriented Medicare Advantage program, and those Medicare Advantage cuts start to kick in in 2013. 27 percent of all seniors are enrolled in Medicare Advantage, including 32 percent in Wisconsin and 36 percent in Ohio.

The chief actuary of the Medicare program, Richard Foster, has estimated that these cuts to Medicare Advantage will force more than half of MA enrollees out of the program. “[Obamacare’s] new provisions will…result in less generous benefit packages. We estimate that in 2017, when the MA provisions will be fully phased in, enrollment in MA plans will be lower by about 50 percent (from its projected level of 14.8 million under the prior law to 7.4 million under the new law).”

Those cuts were supposed to kick in during Obama’s first term. But the Department of Health and Human Services decided to illegally spend $8.4 billion of taxpayer money—without Congressional authorization—to prop up the MA program until the 2012 election. Once the election is over, however, the cuts will come.

In addition, a number of Obamacare’s tax increases will come into effect. The law will, among other things, raise taxes on investment income, itemized medical expenses, privately-sponsored retiree prescription-drug coverage, medical devices, and flexible spending accounts.

2014: Individual mandate, new spending, more taxes

2014 is the critical year for Obamacare. It’s the year that the bulk of the law’s provisions go into effect. Notably, it’s the year that the law’s controversial individual mandate goes into effect, requiring most Americans to buy a government-sanctioned health insurance product. But the mandate is too weak, and will incentivize Americans to skip out on insurance and take advantage of Obamacare’s requirement that insurers take them after they’ve already fallen ill.

In addition, 2014 is the year that Obamacare’s employer mandate begins to be enforced. That mandate requires all businesses with 50 or more workers to provide government-approved health insurance to all of their workers, or face steep fines. In reality, the mandate will encourage many employers to stop hiring full-time workers, or drop coverage so that workers can fall under the law’s subsidized exchanges.

2014 is also the year that Obamacare’s gusher of new spending kicks in, through its expansion of the Medicaid program and the institution of federally subsidized health insurance exchanges. Once these two programs are in place, it will become impossible to repeal Obamacare.

In 2014, Obamacare guts the laws related to consumer-driven health plans, by capping deductibles in the small-group market at $2,000 for individuals and $4,000 for families, down from $6,050 and $12,100 today. By forcing insurers to offer lower deductibles, Obamacare will drive premiums upward, making insurance less affordable, and diminishing the utility of health-savings accounts.

Also, in 2014, Obamacare will force insurers covering small businesses and individuals to cover a set of “essential health benefits” defined by the Secretary of Health and Human Services. By forcing all insurers to cover what Washington wants, regardless of cost, insurance will become more expensive.

In addition, the law will impose a tax on health insurance premiums, though labor unions and government-sponsored plans are exempted from the tax. The premium tax is probably the dumbest provision in Obamacare, and that’s saying a lot: insurers will be forced to pass the cost of the tax onto policyholders, making health insurance less affordable and driving government subsidies upward in compensation.

2015-16: More spending and tax increases

If President Obama is reelected, he will preside over significant spending and tax increases during the latter half of his second term. In 2010, the Congressional Budget Office calculated that the ten-year cost of Obamacare, in terms of its spending increases, was $944 billion. In July of 2012, the CBO’s ten-year spending estimate was $1.9 trillion. By 2015, the CBO’s ten-year spending projections are likely to exceed $2.5 trillion.

Our federal debt exceeds $16 trillion today. Under the Congressional Budget Office’s alternative fiscal scenario—its most realistic estimate of future spending and revenue—Obama’s second term will add another $4 trillion to the federal debt, along with the $6 trillion he incurred in his first term. It wasn’t that long ago—2008, in fact—when Senator Obama called George W. Bush “unpatriotic” for racking up $4 trillion in debt during his eight years in office.

2017 and beyond: Bankrupt hospitals; premium hikes; doctor shortages

Richard Foster, the chief actuary of the Medicare program in the Obama administration, estimates that Obamacare’s cuts to Medicare will drive 15 percent of Medicare providers out of business by 2019, and even more in future years. “Absent other changes,” says Foster, “the lower Medicare payment rates would result in negative total facility margins for an estimated 15 percent of hospitals, skilled nursing facilities, and home health agencies by 2019, and this percentage would reach roughly 25 percent in 2030 and 40 percent by 2050.”

Obama adviser Jonathan Gruber, who was heavily involved in designing Obamacare’s insurance regulations, calculates that the law will significantly drive up health insurance premiums in the non-group market: by 2016, premiums will go up by an average of 19 percent in Colorado, and 30 percent in Wisconsin, relative to what they would have been without Obamacare. And that’s the average; due to Obamacare’s community rating provision, premiums for young people will go up even more.

In addition, the law will make it harder for tens of millions of Americans to see their doctors, especially those with government-sponsored health insurance. Just as the baby boomers are retiring, requiring more health care, baby boomer physicians will also be retiring. As a result, even without Obamacare, we’ll have less doctors per capita than we need. On top of that, Obamacare will subsidize increased health-care consumption by $1.9 trillion, without increasing the supply of physicians. Under such a system, patients with government-sponsored insurance, who pay less than private insurers, will move to the back of the line.

So far, the case against Obamacare has been about what the law will do in the future. If President Obama is reelected, the future will be at hand.

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Now this is how you write an article! Thank you for bringing a lot of these facts to light because we literally cannot afford four more years of this president. I hope Romney starts to use that “unpatriotic” line against Obama when it comes to the debt.

First, the $156 billion in savings from Medicare Advantage (MA) is a drop in the bucket compared to what the government pays the private insurance companies that provide MA. MA cost taxpayers about $127 billion last year. Over ten years, these cuts represent well under a 10% reduction in payments to private MA insurers, which are already heavily subsidized.

Avik refers to a 2010 analysis by the CBO that says Obamacare would “force” more than half the enrollees out of the MA. But let’s look at the most recent analysis that CBO did for John Boehner (http://www.cbo.gov/sites/default/files/cbofiles/attachments/43471-hr6079.pdf). This analysis finds that more people are actually enrolling in MA, and will continue to. “CBO has increased the number of Medicare beneficiaries who are projected to be enrolled in the Medicare Advantage program (and reduced the number of beneficiaries estimated to be enrolled in the fee-for-service component of Medicare).” Beneficiaries are flocking to MA, not leaving it. It seems an odd assertion that MA plans are preparing for massive cuts to the subsidies they receive from the government by enrolling huge numbers of new beneficiaries, whom Avik says will be forced to receive lower benefits packages. Not what CBO says.

But let’s talk about the idea of MA in the first place. It is supposed to be a way for insurers to compete by offering coverage packages that allow beneficiaries to choose the best plan for them, and drive down costs. But that hasn’t worked. MA is on average 117% higher on a per-patient cost than fee-for-service.

The worries about federal debt are legitimate, which is why we should acknowledge that repealing Obamacare would increase the deficit by over $100 billion dollars, according to the CBO in its letter to Boehner. Avik is conflating Obamacare’s impact on the deficit and other federal spending. Obamacare saves money and does not contribute to an increase in the deficit. Repealing Obamacare increases the deficit. Wars have cost taxpayers trillions since 2001. (Remember, this blog has cited a “first-rate” military as the main priority.)

What kind of health care programs will we see under a Romney administration? Well, if Romney sticks to his guns and delivers on promises to “to cap total federal spending at 20 percent of gross domestic product (GDP) and boost defense spending to 4 percent of GDP,” then there will be massive cuts to health programs. The Center for Budget and Policy Priorities has looked closely at the Romney scenarios, and it is not pretty (http://www.cbpp.org/cms/?fa=view&id=3658)

-“If Medicare is subject to cuts, that program would be cut by a net of $95 billion in 2016 and $1.0 trillion from 2014 through 2022.”

-“Medicaid and the Children’s Health Insurance Program (CHIP) would face cumulative cuts of $1.5 trillion through 2022 if Medicare is subject to cuts and $1.9 trillion if Medicare is exempt. Repealing health reform’s coverage expansions, as Governor Romney has proposed, would reduce Medicaid spending by $618 billion over the next ten years and account for 30 to 40 percent of the reductions. Repealing health reform by itself would leave uninsured 30 million people who would have gained coverage under health reform, according to CBO.”

The choice is between a favorable impact on the federal deficit and 30 million more insured under Obama and cutting Medicare by $1.0 trillion under Romney. Or maybe Romney would keep Medicare and just cut Medicaid by $1.9 trillion and leave millions of the poor and their children uninsured.

You really should get some knowledge of how insurance works and how Medicare works before you start posting nonsense:

You say “the government pays the (Part A/B/C Medicare health plan) insurance companies that provide (Part A/B/C Medicare health insurance) $127 billion” a year. The government is not paying the insurers just for the hell of it as you want readers to think; those insurers are paying for my health care. Second, while the government is paying Part A/B/C Medicare health plan insurers $127 billion a year, it is also paying Part A/B Medicare insurers $400 billion a year. So what?

You say recent “analysis finds that more people are actually enrolling in MA, and will continue to. “ Do you think that is some brilliant revelation on your part? That is exactly what Roy described. Of course, we seniors will continue to enroll in A/B/C as long as Obama illegally bribes the Part A/B/C healthcare insurers to give us seniors on A/B/C a better deal than those seniors on a combination of A/B Medicare and Medigap.

As Roy says, that ends next year, conveniently after the election. The “lower benefits packages” and reduced enrollment come after the election. That’s not what Roy says. That’s what the Medicare trustees and actuary say.

Then you say “But let’s talk about the idea of MA in the first place.” But you go on to quote a lot of bad data and do not take into account the actual data and the disservice you are doing to the poor. The highest priced Part A/B/C Medicare health plans (and your 17% statistic is wrong–go read the Medicare Trustees’ reports on the subject) are used disproportionately by those seniors in rural locations where medical coverage is highly spread out so that an HMO concept won’t work and by the urban poor who just plain need assistance. The regular HMOs that most of us seniors on Part A/B/C Medicare health plan belong to actually cost the government 95% of what Part A/B fee for service Medicare costs per person. But if you want to screw the poor, go ahead.

And the real cuts to Medicare from Obamacare (and I am using the word “cuts” the same way Democrats have always used it– to mean reductions in spending from otherwise higher levels) affect Part A/B FFS Medicare more than they affect me on a regular A/B/C HMO plan. There are twice as many seniors on Part A/B FFS (and they are also spending a lot of money out of their own pockets for private insurance that I don’t have to buy) as there are seniors like me on a Part A/B/C Medicare health plan. The cuts in FFS funding is three times higher than the cuts to A/B/C.

So your argument is to screw the poor and screw people on “Medicare as we know it.”

Bernard, by your logic, I am “subsidizing” Macy’s every time I buy a shirt from them.

Plus, as Rodney Dangerfield said to the stuffy perfesser in “Back to School” – you’re leaving out a whole lotta stuff.

For example you ignore the analysis of the Medicare Chief Actuary and you also ignore the so-called Medicare “doc fix”. The doc fix was split off into a separate bill from ObamaCare right after the CBO concluded that ObamaCare as then written would significantly increase the deficit. But the doc fix still entails significant cost. Congress simply moved that pea under a different shell and CBO adjusted its ObamaCare analysis accordingly. But now, CBO’s analysis no longer reflects the full cost of the legislation – for the missing part, one must include the Medicare Actuary’s analysis. Here is a comment from Heritage Foundation about the Medicare Actuary’s report:

“The president says the legislation will slow the pace of rising costs; the actuary says it won’t. The president says people will get to keep their job-based plans if they want to; the actuary says 14 million people will lose their employer coverage, many of whom would certainly rather keep it than switch into an untested program. The president says the new law will improve the budget outlook; in so many words, the chief actuary says, don’t bet on it.”

Here’s the link to the above paragraph: http://blog.heritage.org/2010/05/25/obamacares-cooked-books-and-the-doc-fix/

There is much more in the linked story, and many other links to other reputable and credible sources that report the same set of facts – facts you leave out that change the picture you attempt to paint.

With all due respect, no. Medicare Advantage insurers are the only private insurers Medicare pays, outside of the Part D prescription drug plans, which are all private companies. People who aren’t in Medicare Advantage (MA includes what you are on, also the plans known as “Medicare private fee-for-service”) are in original fee for service Medicare. That means that Medicare pays the providers (i.e. doctors, hospitals) directly. No other insurer is involved. No “illegal bribing” involved.

You’re also wrong about Medicare Advantage being cheaper than regular Medicare. Simply not true. “So what?” The government is paying MORE for Medicare Advantage than they do on original fee-for-service, even after adjusting for how sick and/or poor the patient is. It is therefore an insurance company subsidy.

Originally, yes, Medicare Advantage plans were supposed to receive only 95% of what Medicare would otherwise pay to cover those beneficiaries. However, that quickly changed. Now, the payments are much higher. “MedPAC estimates that Medicare payments to MA plans in 2008 average 113% of FFS costs for the counties where MA enrollees reside and as much as 117% for PFFS plans on average before adjusting for enrollee risk.” (http://www.kff.org/medicare/upload/2052-11.pdf) I linked to my “bad data” for you there.

Unbiased third parties have found Romney’s claim that Obamacare will cause 20 million to lose their employer insurance false. Heritage is a conservative think tank funded by the Koch brothers and their analyses are predictably one sided, although I do read them because it is important to consider all viewpoints.

Politifact gave Romney’s claim about 20 million losing their insurance under Obamacare a “false” on its truth-o-meter. Romney’s figure includes 9 million people who wouldn’t have even had an employer insurance plan and another 3 million people who will turn down their employer’s plan for a better insurance option. “CBO projects that, overall, the number of uninsured Americans will drop by 29 million to 31 million due to the law.”

MA plans are subsidized because the government could provide the same care to the same people in original Medicare for less than the payments to the MA plans. When coming from the government, that is a subsidy.

The doc fix you refer to is something that has not been done in solved in many years and has been an ongoing issues since well before Obama came into office. That issue does not have anything to do with how much Obamacare will save (as is the case) or cost.

(1) “Unbiased third parties have found Romney’s claim that Obamacare will cause 20 million to lose their employer insurance false.”

Bernard, would you kindly supply a link to a couple of your favorite unbiased third parties? I mean other than the Tampa Bay Times.

You say “Politifact [Tampa Bay Times] gave Romney’s claim about 20 million losing their insurance under Obamacare a “false” on its truth-o-meter. Romney’s figure includes 9 million people who wouldn’t have even had an employer insurance plan and another 3 million people who will turn down their employer’s plan for a better insurance option.” Let’s set aside that Romney did not claim 20 million would lose their insurance under ObamaCare; even your source acknowledged that – it’s another of the things you leave out. Again according to your source, the CBO estimated “the impact of the health care law on the number of people obtaining health care coverage from their employer.” In other words, your source suggests the correct number is 8 million people (20-9-3) who will lose their employer-based insurance under ObamaCare.

Avik’s article above contains a link to the Medicare Actuary’s report dated April 22, 2010 which states “We estimate that in 2017, when the MA provisions will be fully phased in, enrollment in MA plans will be lower by about 50 percent”. The Actuary’s report also says that in 2017, the estimated enrollment under prior law would have reached 14.8 million. The reduction in MA enrollment by 2017 would thus be about 7.4 million.

The sum of the estimated enrollment losses of employer-based insurance and Medicare Advantage insurance thus amount to between 15 million and 16 million people. The clear conclusion is that millions of American will lose the insurance of their choice when ObamaCare is fully implemented. Other than that, your statement is accurate.

(2) “Heritage is a conservative think tank funded by the Koch brothers and their analyses are predictably one sided”

Your analyses seem to me equally predictable. However, Heritage does not handicap itself by using distinctly ad hominem arguments. Other than that, your statement is accurate.

(3) “the government could provide the same care to the same people in original Medicare for less than the payments to the MA plans.”

“for less than the payments to MA” – - again, you’re leaving out a whole lotta stuff. Here’s what GAO has to say (http://www.gao.gov/products/GAO-12-93):

“MA plans generally receive larger payments from Medicare than what these plans would require to provide the original Medicare FFS benefit package. Plans must use this additional money to reduce cost sharing, reduce premiums, and offer additional benefits.”

Got that? When Medicare pays higher premiums to private MA insurers, those insurers MUST spend the excess: (a) to reduce cost-sharing, (b) to reduce members’ premiums, or (c) to add more benefits. This explains why my Medicare Advantage coverage has a lower deductible, a maximum yearly out-of-pocket cost, unlimited lifetime benefits, and world-wide coverage – all better than original Medicare. But my premium is the same as Original Medicare.

So Bernard, MA does much more than deliver “the same care to the same people”.

Other than that, your statement is accurate.

(4) “The doc fix you refer to is something that has not been done in solved in many years”

And I do not suggest otherwise but, again, you’re leaving out a whole lotta stuff. I am saying that a doc fix was a part of the early versions of ObamaCare and was stripped from that legislation to reduce cost when it became clear that ObamaCare including the doc fix would increase the deficit. Stripping out the doc fix was legislative sleight of hand. Scandalous? Not really. It’s just how things are done in Washington. Another example is counting 10 years of ObamaCare revenue against 7 years of operational costs during its first decade in order to improve the numbers. Anyway, other than that, your statement is accurate.

1) Another unbiased source on Romney’s 20 million claim? How about the Washington Post? They also found it to be misleading. http://www.washingtonpost.com/blogs/fact-checker/post/a-greatest-hits-of-misleading-romney-claims/2012/10/20/aa932626-1af4-11e2-aa6f-3b636fecb829_blog.html According to CBO, the worst case scenario is a loss of 20 million employer based insurance policies. The best case scenario is an increase of 3 million. However, the CBO says that even among those few who could lose their employer based insurance aren’t actually losing insurance—they will be insured and getting better deals elsewhere. Also, the employer compensation that otherwise would have gone toward their premiums will go back into their salaries. “If a firm chose not to offer insurance coverage under the ACA, some of its workers and their families might enroll in Medicaid or CHIP or be eligible to receive subsidies through the insurance exchanges; as a result, the cost of those programs would increase. At the same time, the reduction in that firm’s compensation to workers that was provided in the form of health benefits would generally be offset by an increase in the compensation it provided in the form of wages and salaries.” http://www.cbo.gov/sites/default/files/cbofiles/attachments/03-15-ACA_and_Insurance_2.pdf

So more people are getting insurance, not losing it. And they are getting paid more because their employers will no longer be the source of the insurance.

2) I see you don’t care to challenge the one-sidedness of Heritage’s analyses. Funny how an organization’s funding sources align so well politically with the products they put out. Clearly, the people who sign on to work at Heritage are right leaning so it isn’t a surprise to see them trash Obamacare. Show me one report they’ve put out that says anything positive about the health law and we’ll talk. And no, I am not counting any analyses they put out back when the health law’s main provisions were conservative ideas.

Also, bringing the Koch brothers’ support of Heritage isn’t an ad hominem attack. It is just a fact—they are ideologically conservative and those are the types of organizations they fund. Find me a reasonable person that would argue with that. I am not calling them terrible people or Heritage an evil institution. If it is your opinion that “conservative” or “right wing” implies “bad” then ok, but that is not what I’m saying.

3) “MA plans generally receive larger payments from Medicare than what these plans would require to provide the original Medicare FFS benefit package. Plans must use this additional money to reduce cost sharing, reduce premiums, and offer additional benefits.” Ok, but don’t you see that Medicare is paying MORE for your plan than they would to insure you through regular fee-for-service? Got that? The payments are inflated. MA costs more. If someone on fee for service, they don’t get whatever extra services or lower copayments you receive, so there is a cost to this. Also, these are private companies, so they are making money off of MA. They don’t do it out of their kindness of their hearts. I hope that makes sense.

4) The doc fix wasn’t in Obamacare primarily because it is a pain in the butt to do. Same reason that it hasn’t been “fixed” in years and years. I’m not saying that gaming the numbers played absolutely no role in the decision making on that provision, but pretty much any legislation costed out by CBO gets rejiggered to seem more favorable at some point.

(1) “Another unbiased source on Romney’s 20 million claim? How about the Washington Post?”

Unbiased? The Washington Post? Oh,please.

Based on the “unbiased” Tampa Bay Times source that you previously cited, together with the Medicare Actuary’s analysis, the sum of the estimated enrollment losses of employer-based insurance and Medicare Advantage insurance amount to between 15 million and 16 million people. The clear conclusion is that millions of American will lose the insurance of their choice when ObamaCare is fully implemented.

ObamaCare takes that choice away from employees and seniors despite Obama’s repeated pledge that if we like the insurance we have, we can keep it.

(2) “If it is your opinion that “conservative” or “right wing” implies “bad” then ok, but that is not what I’m saying.”

What you’ve been saying is that Heritage analyses are unacceptable because Heritage is funded by conservatives. That’s ad hominem.

(3) “Ok, but don’t you see that Medicare is paying MORE for your plan than they would to insure you through regular fee-for-service?”

Sure, and so what? Medicare pays more only because my Medicare Advantage plan has better benefits than original Medicare. And my plan has better benefits because that’s what Medicare’s own rules for MA plans allow and require. Wouldn’t I be foolish not to choose better benefits for the same premium? I’m not alone. More than 12 million Medicare-eligible seniors have chosen a private Medicare Advantage plan, about 25% of us. ObamaCare will take that choice away.

Recall that Obama has further stated he wants to end Medicare Advantage. And why not? Its very existence is evidence that a sweeping national program such as he believes in is not necessary to provide superior private-sector insurance. Governments do not like competition. They prefer to use their power to destroy competition because that relieves them of any public pressure to respond to competition by, you know, performing better. I think it’s clear that MA is competing only too well with ObamaCare and therefore must be destroyed.

(4) You also say “these . . . private companies . . .are making money off of MA”. But by law, private insurers must spend any premium above the benchmark cost of Original Medicare on reducing member cost, or increasing benefits, or both. So where does the profit come from? I suggest it comes from managing the original Medicare benefits for less cost than Medicare could, or would. In other words, the private companies are earning their profit.

(5) “The doc fix wasn’t in Obamacare primarily because it is a pain in the butt to do.”

Bernard, the doc fix WAS in Obamacare as originally drafted. It was put there deliberately. After one of the CBO analyses, the sponsors of PPACA realized it had to be REMOVED to make ObamaCare appear less costly. The doc fix was eventually enacted as separate legislation. You may be thinking of HHS’ 2011 shutdown of the CLASS Act.